Reason for visit: relief from fatigue and pain is caused by getting wet from bathing.
Past Medical History
1965: Came back from vacation and did not feel rested. Chronic fatigue began at this time and is now dramatic. [Patient] can only spend seven hours per day out of bed due to fatigue.
1968: Chronic widespread pain began with pain in the chest.
1969: Extreme fatigue developed as well as widespread pain (most severe in the abdomen) and "muscle buzzing".
1974: After a shower [patient] developed fatigue and muscle pain. this has progressed to severe pain if water touches more than a small portion of his body. For two years now only Norco can relieve the pain. Pain is intolerable with discomfort everywhere and extreme abdominal pain and fatigue.
Other conditions: status post colon cancer, status post esophageal cancer, history of prostate cancer, history of gastric bleed, adrenal adenoma.
Results of recent lab tests: normal TSH, normal T3, vitamin D 37, ferritin 30, normal CBC
Medications: Methylphenidate twice a day, Brintellix, Wellbutrin, Pantoprazole, docusate sodium when takes Norco, Cholestyramine, Rexulti, Terazosin, Ziprasidone, Norco prn, Acetaminophen prn.
Allergies: Mold, feathers, ragweed, welchol, tamsulosin
Sleep: takes one hour to fall asleep, wakes at night to urinate, wakes feeling rested but then is extremely fatigued throughout the day
Habits: denies caffeine, alcohol, cigarettes, cannabis
Limitations: severe fatigue. Out of bed only about seven hours per day
Exercise: walks around the block once per day. If does additional exercise crashes and becomes even more fatigued for a time.
Current most bothersome problems: dramatic fatigue, increased muscle pain when gets wet from bathing
Answers to the fibromyalgia questionnaire: when [patient] was asked questions common in people with fibromyalgia, he answered yes to having fatigue, depression, insomnia, impaired concentration, mildly impaired memory, nasal congestion, ringing ears, rash (diagnosed as psoriasis), allergies, widespread body pain.
Physical exam: [patient] was alert and oriented during the entire exam. He had good skin color and tone. He had 45 nodules consistent with a diagnosis of fibromyalgia using the mapping technique pioneered by fibromyalgia specialist Dr. Paul St. Amand, Associate Professor at Harbor UCLA Medical Center.
Assessment:
1. Fibromyalgia--with chronic widespread pain, dramatic fatigue, and other symptoms such as ringing ears, rash, insomnia, depression, and impaired concentration and memory, [Patient] meets the diagnostic criteria for fibromyalgia. He has many nodular swellings throughout his body. Fibromyalgia expert Dr. R. Paul St. Amand has found that swellings of the left anterior thigh are present in all patients with fibromyalgia. I believe that fibromyalgia is the underlying driver of most of [patient's] symptoms. I find no other condition that could explain his symptoms.
2. History of colon cancer, esophageal cancer, gastric bleed, currently has prostate cancer.
Plan:
1. Fibromyalgia. [Patient] and I discussed what is known about fibromyalgia, including the possible locus on chromosome 17 that codes for the disorder, as well as the common treatments using pharmaceuticals. In my professional experience, the "game changer" for successful fibromyalgia recover include 1)eating foods that help you feel well, 2) getting consistent aerobic exercise, 3) clearing nodules while on the guaifenesin protocol, 4) staying well hydrated and, 5) balancing the autonomic nervous system with mind body therapies. I gave [patient] a copy of Dr. St. Amande's book What Your Doctor May Not Tell You About Fibromyalgia, my favorite general review of fibromyalgia and its various treatments, and my favorite specific review of the guaifenesin protocol. I recommend [patient] do the following:
* Continue to eat as healthfully as possible
* Begin a graduated exercise program. Fibromyalgia is a energy deprivation condition, and building new mitochondria is critical to recovery. {Patient} is to add 1 minute of exercise per week to his current exercise regimen (walking 1/2 block more each day) and then add an additional 1/2 block per week to his regimen until he is walking at least 20 minutes/day. This graduated exercise program has been extremely successful in building new mitochondria which increases energy, promotes more restful sleep, decreases pain, and improves mood. If [patient] has increased symptoms at any point he is to increase his exercise amount more slowly.
* Continue to stay well hydrated (the Mayo Clinic recommends drinking between 48 - 62 oz. of water a day and [patient] is doing that.
* Increasing vitamin D supplementation to try to achieve a level of around 50.
* Consider ways to increase ferritin level to 50. (is at 30 now), as some fibromyalgia patients with severe fatigue feel better with higher ferritin levels.
* [Patient] is interested in learning more about this protocol, and I heartily agree. This safe over the counter medication has been used for 21 years by thousands of fibromyalgia sufferers around the world to reverse their symptoms over time. Guaifenesin works by decreasing the size and number of the swellings (nodules) in the bodies of fibromyalgia patients, and as the nodules size/number decrease, patients often feel better. Many fibromyalgia patients whose nodules decrease on guaifenesin can wean off of some (or all) of their prescription medications over time. [Patient] and I will discuss this protocol at his follow up visit.
2. History of colon and esophageal cancers, gastric bleed, current prostate cancer--plan per specialist.
It was a pleasure to meet [patient]. He is set up with a joint appointment next month with Dr. MC and myself to review progress and make plan for the future.
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